Exploring the Feasibility of Service Integration in a Low-Income Setting: A Mixed Methods Investigation into Different Models of Reproductive Health and HIV Care in Swaziland.

Integrating reproductive health (RH) with HIV care is a policy priority in high HIV prevalence settings, despite doubts surrounding its feasibility and varying evidence of effects on health outcomes. The process and outcomes of integrated RH-HIV care were investigated in Swaziland, through a comparative case study of four service models, ranging from fully integrated to fully stand-alone HIV services, selected purposively within one town. A client exit survey (n=602) measured integrated care received and unmet family planning (FP) needs. Descriptive statistics were used to assess the degree of integration per clinic and client demand for services. Logistic regression modelling was used to test the hypothesis that clients at more integrated sites had lower unmet FP needs than clients in a stand-alone site. Qualitative methods included in-depth interviews with clients and providers to explore contextual factors influencing the feasibility of integrated RH-HIV care delivery; data were analysed thematically, combining deductive and inductive approaches. Results demonstrated that clinic models were not as integrated in practice as had been claimed. Fragmentation of HIV care was common. Services accessed per provider were no higher at the more integrated clinics compared to stand-alone models (p>0.05), despite reported demand. While women at more integrated sites received more FP and pregnancy counselling than stand-alone models, they received condoms (a method of choice) less often, and there was no statistical evidence of difference in unmet FP needs by model of care. Multiple contextual factors influenced integration practices, including provider de-skilling within sub-specialist roles; norms of task-oriented routinised HIV care; perceptions of heavy client loads; imbalanced client-provider interactions hindering articulation of RH needs; and provider motivation challenges. Thus, despite institutional support, factors related to the social context of care inhibited provision of fully integrated RH-HIV services in these clinics. Programmes should move beyond simplistic training and equipment provision if integrated care interventions are to be sustained

Health system strengthening—Reflections on its meaning, assessment, and our state of knowledge

Sophie Witter - ORCID 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Comprehensive reviews of health system strengthening (HSS) interventions are rare, partly because of lack of clarity on definitions of the term but also the potentially huge scale of the evidence. We reflect on the process of undertaking such an evidence review recently, drawing out suggestions on definitions of HSS and approaches to assessment, as well as summarising some key conclusions from the current evidence base. The key elements of a clear definition include, in our view, consideration of scope (with effects cutting across building blocks in practice, even if not in intervention design, and also tackling more than one disease), scale (having national reach and cutting across levels of the system), sustainability (effects being sustained over time and addressing systemic blockages), and effects (impacting on health outcomes, equity, financial risk protection, and responsiveness). We also argue that agreeing a framework for design and evaluation of HSS is urgent. Most HSS interventions have theories of change relating to specific system blocks, but more work is needed on capturing their spillover effects and their contribution to meeting overarching health system process goals. We make some initial suggestions about such goals, to reflect the features that characterise a “strong health system.” We highlight that current findings on “what works” are just indicative, given the limitations and biases in what has been studied and how, and argue that there is need to rethink evaluation methods for HSS beyond finite interventions and narrow outcomes. Clearer concepts, frameworks, and methods can support more coherent HSS investment.Department for International Development, Grant/Award Number: Supported by the ReBUILD and ReSYST RPCshttps://doi.org/10.1002/hpm.288234pubpub

FISHGLOB: A collaborative infrastructure to bridge the gap between scientific monitoring and marine biodiversity conservation

\ua9 2025 The Author(s). Conservation Science and Practice published by Wiley Periodicals LLC on behalf of Society for Conservation Biology. Large-scale biodiversity assessments and conservation applications require integrated and up-to-date datasets across regions. In the oceans, monitoring is fragmented, which affects knowledge exchange and usage. Among existing monitoring programs, scientific bottom-trawl surveys (SBTS) are long-term, rich, and well-maintained data sources at the scale of each sampled region, but these data are under-utilized in biodiversity applications, especially across regions. This is hampered by the lack of an international community and database maintained through time. To address this, we created FISHGLOB, an infrastructure gathering SBTS and experts. In 5 years, we developed an integrated database of SBTS and a consortium gathering more than 100 experts and users. Here, we are sharing the project history, achievements, challenges, and outlooks. In particular, we reflect on the infrastructure-building social and technical processes which will guide the development of similar infrastructures. The FISHGLOB project takes ocean monitoring one step forward in working as a unified community across disciplines and regions of the world

Prevalence and risk factors for Hepatitis C and HIV-1 infections among pregnant women in Central Brazil

<p>Abstract</p> <p>Background</p> <p>Hepatitis C (HCV) and human immunodeficiency virus (HIV) infections are a major burden to public health worldwide. Routine antenatal HIV-1 screening to prevent maternal-infant transmission is universally recommended. Our objectives were to evaluate the prevalence of and potential risk factors for HCV and HIV infection among pregnant women who attended prenatal care under the coverage of public health in Central Brazil.</p> <p>Methods</p> <p>Screening and counselling for HIV and HCV infections was offered free of charge to all pregnant women attending antenatal clinic (ANC) in the public health system, in Goiania city (~1.1 million inhabitants) during 2004–2005. Initial screening was performed on a dried blood spot collected onto standard filter paper; positive or indeterminate results were confirmed by a second blood sample. HCV infection was defined as a positive or indeterminate sample (EIA test) and confirmed HCV-RNA technique. HIV infection was defined according to standard criteria. Factors associated with HIV and HCV infections were identified with logistic regression. The number needed to screen (NNS) to prevent one case of infant HIV infection was calculated using the Monte Carlo simulation method.</p> <p>Results</p> <p>A total of 28,561 pregnant women were screened for HCV and HIV-1 in ANC. Mean maternal age was 23.9 years (SD = 5.6), with 45% of the women experiencing their first pregnancy. Prevalence of HCV infection was 0.15% (95% CI 0.11%–0.20%), and the risk increased with age (p < 0.01). The prevalence of anti-HIV infection was 0.09% (95% CI 0.06%–0.14%). Black women had a 4.9-fold (95% CI 1.42–16.95) greater risk of HIV-1 infection compared to non-black women. NNS to prevent one case of infant HIV infection ranged from 4,141 to 13,928.</p> <p>Conclusion</p> <p>The prevalence of HIV and HCV infections were low among pregnant women, with high acceptability rates in the opt-in strategy in primary care. Older maternal age was a risk factor for HCV and antenatal HCV testing does not fulfill the requirements for screening recommendation. The finding of higher risk of HIV-1 infection among black women despite being in consonance with the HIV-1 ethnic pattern in some American regions cannot be ruled out to be a surrogate marker of socio-economic condition.</p

A census of baryons in the Universe from localized fast radio bursts

More than three quarters of the baryonic content of the Universe resides in a highly diffuse state that is difficult to observe, with only a small fraction directly observed in galaxies and galaxy clusters. Censuses of the nearby Universe have used absorption line spectroscopy to observe these invisible baryons, but these measurements rely on large and uncertain corrections and are insensitive to the majority of the volume, and likely mass. Specifically, quasar spectroscopy is sensitive either to only the very trace amounts of Hydrogen that exists in the atomic state, or highly ionized and enriched gas in denser regions near galaxies. Sunyaev-Zel'dovich analyses provide evidence of some of the gas in filamentary structures and studies of X-ray emission are most sensitive to gas near galaxy clusters. Here we report the direct measurement of the baryon content of the Universe using the dispersion of a sample of localized fast radio bursts (FRBs), thus utilizing an effect that measures the electron column density along each sight line and accounts for every ionised baryon. We augment the sample of published arcsecond-localized FRBs with a further four new localizations to host galaxies which have measured redshifts of 0.291, 0.118, 0.378 and 0.522, completing a sample sufficiently large to account for dispersion variations along the line of sight and in the host galaxy environment to derive a cosmic baryon density of $\Omega_{b} = 0.051_{-0.025}^{+0.021} \, h_{70}^{-1}$ (95% confidence). This independent measurement is consistent with Cosmic Microwave Background and Big Bang Nucleosynthesis values.Comment: Published online in Nature 27 May, 202

Choice-Disability and HIV Infection: A Cross Sectional Study of HIV Status in Botswana, Namibia and Swaziland

Interpersonal power gradients may prevent people implementing HIV prevention decisions. Among 7,464 youth aged 15–29 years in Botswana, Namibia and Swaziland we documented indicators of choice-disability (low education, educational disparity with partner, experience of sexual violence, experience of intimate partner violence (IPV), poverty, partner income disparity, willingness to have sex without a condom despite believing partner at risk of HIV), and risk behaviours like inconsistent use of condoms and multiple partners. In Botswana, Namibia and Swaziland, 22.9, 9.1, and 26.1% women, and 8.3, 2.8, and 9.3% men, were HIV positive. Among both women and men, experience of IPV, IPV interacted with age, and partner income disparity interacted with age were associated with HIV positivity in multivariate analysis. Additional factors were low education (for women) and poverty (for men). Choice disability may be an important driver of the AIDS epidemic. New strategies are needed that favour the choice-disabled

An evolving jet from a strongly magnetized accreting X-ray pulsar

© 2018, Springer Nature Limited. Relativistic jets are observed throughout the Universe and strongly affect their surrounding environments on a range of physical scales, from Galactic binary systems1 to galaxies and clusters of galaxies2. All types of accreting black hole and neutron star have been observed to launch jets3, with the exception of neutron stars with strong magnetic fields4,5 (higher than 1012 gauss), leading to the conclusion that their magnetic field strength inhibits jet formation6. However, radio emission recently detected from two such objects could have a jet origin, among other possible explanations7,8, indicating that this long-standing idea might need to be reconsidered. But definitive observational evidence of such jets is still lacking. Here we report observations of an evolving jet launched by a strongly magnetized neutron star accreting above the theoretical maximum rate given by the Eddington limit. The radio luminosity of the jet is two orders of magnitude fainter than those seen in other neutron stars with similar X-ray luminosities9, implying an important role for the properties of the neutron star in regulating jet power. Our result also shows that the strong magnetic fields of ultra-luminous X-ray pulsars do not prevent such sources from launching jets

The benefits and risks of bacille Calmette-Guérin vaccination among infants at high risk for both tuberculosis and severe combined immunodeficiency: assessment by Markov model

BACKGROUND: Bacille Calmette-Guérin (BCG) vaccine is given to Canadian Aboriginal neonates in selected communities. Severe reactions and deaths associated with BCG have been reported among infants born with immunodeficiency syndromes. The main objective of this study was to estimate threshold values for severe combined immunodeficiency (SCID) incidence, above which BCG is associated with greater risk than benefit. METHODS: A Markov model was developed to simulate the natural histories of tuberculosis (TB) and SCID in children from birth to 14 years. The annual risk of tuberculous infection (ARI) and SCID incidence were varied in analyses. The model compared a scenario of no vaccination to intervention with BCG. Appropriate variability and uncertainty analyses were conducted. Outcomes included TB incidence and quality-adjusted life years (QALYs). RESULTS: In sensitivity analyses, QALYs were lower among vaccinated infants if the ARI was 0.1% and the rate of SCID was higher than 4.2 per 100,000. Assuming an ARI of 1%, this threshold increased to 41 per 100,000. In uncertainty analyses (Monte Carlo simulations) which assumed an ARI of 0.1%, QALYs were not significantly increased by BCG unless SCID incidence is 0. With this ARI, QALYs were significantly decreased among vaccinated children if SCID incidence exceeds 23 per 100,000. BCG is associated with a significant increase in QALYs if the ARI is 1%, and SCID incidence is below 5 per 100,000. CONCLUSION: The possibility that Canadian Aboriginal children are at increased risk for SCID has serious implications for continued BCG use in this population. In this context, enhanced TB Control – including early detection and treatment of infection – may be a safer, more effective alternative